PEDIATRICS 1 5M Preventive Pediatics: Part 1

Midterm Quiz Dr. Elizabeth Escano-Gallardo | March 21, 2016

“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE” • Examples:

o Providing chest physiotherapy for a child with cystic
BLACK: Slides | BLUE/ITALICS: Audio | RED: EMPHASIZED | VIOLET: OT fibrosis
PREVENTIVE PEDIATRICS o Rehabilitation therapy
• Must be given the same importance as the care of sick o Speech therapy
children (for me, personally, more importance) o Behavioral therapy
• Both prevention and cure are equally needed to
promote the optimum health of an infant from the time DIFFERENT PERIODS IN THE LIFE OF A CHILD
of conception until adulthood • Preconception
• Prevention is much cheaper and relatively easier to • Prenatal and neonatal periods
undertake • Infancy
• Preschool
OBJECTIVES • School age
• To provide anticipatory guidance (proper education) to • Puberty and adolescence
patients and parents on health maintenance practices in • Adult
an ambulatory care setting according to age groups: Goal: Reach the healthy adult stage
o Newborn, infant, childhood and adolescence
• To recommend and administer indicated childhood Prevention starts even before the child is conceived/born so it
vaccinations at various age groups and situations starts during the preconception period
• To discuss growth and developmental monitoring PRECONCEPTION
MOST IMPORTANT & (monitor stunting and wasting) • Thinking about having a baby
• To explain the nutritional requirements according to • Best time to give preconception counseling for
age group and aspects of nutrition (prevent subsequent babies is right after birth/delivery
malnutrition) – look into feeding hx. • Proper spacing of pregnancies and need to limit the
• To obtain a thorough, adequate and dynamic history number of children per family especially in multiparous
mothers.
PREVENTIVE PEDIATRIC HEALTH CARE o Interval between pregnancies for optimum health
of both mother and child is at least 3 years
1. PRIMARY PREVENTION o Multiparity poses a lot of complications like
• Directed at avoiding a disorder before they begin premature labor and delivery, higher morbidity
• Special emphasis on those at increased risk to develop a o “It takes a while to go back to pre-pregnancy state;
condition or disease. allow your body to heal”
• “Aim of a physician”*** • Genetic counseling among couples with heredofamilial
• Examples: diseases
o Chlorination and fluoridation of water o Hemophilia
o Immunization (rotavirus and pneumococcal o X-linked, autosomal recessive, autosomal dominant
vaccination) diseases
o Counseling about keeping poisons and drugs out of o Important if there is a history of bad outcome of
reach previous pregnancies -> Talk to parents
o “Discuss options and implications of getting
2. SECONDARY PREVENTION pregnant (chances of getting another stillbirth,
• Those in which a condition or its precursor is identified preterm delivery or a condition to be avoided)”
early (so you can intervene) and effective treatment is
instituted to remedy the condition before progression PRENATAL AND NEONATAL
or for elimination of the precursor • Directed towards preparing prospective parents for
• Examples: parenthood in order to develop a healthy parent-child
o Screening programs for blood lead levels relationship
o Screening for adolescent scoliosis (forward bend • Done with the OB Gynecologist
test) • Prenatal education may be done through a structured
o Newborn Screening mother’s class or face to face counseling with a health
o Newborn Hearing Test care professional or worker (ex. Nat’l Buntis Day)
• Education and counseling must include the following
3. TERTIARY PREVENTION areas of concern:
• Directed at ameliorating or halting the disabilities from o Breastfeeding (Advantages & Mother’s concerns)
established disease. ▪ Discussed during prenatal period
• It’s late because the disease has already ran its course.
 o Newborn care and procedure ▪ use sterile cloth, do not wipe away vernix caseosa
▪ Prime the mother on what to expect during because it adds warmth, change cloth after wiping
delivery • Early skin to skin contact on mother’s chest (within the
▪ Ex. Vaccinations are abhored by some parents next 30 seconds) and delaying washing/bathing for at
but convince why vaccines are needed and least 6 hours of life
what are the implications of non-immunization. o Facilitates bonding and breastfeeding
o Anticipatory guidance to decrease the risk of injury o Promote oxytocin reflex when the mother sees the
and identify risk factors for child maltreatment baby for the first time – milk let down & breastfeed
▪ Risk for child maltreatment – unwanted o Bathing is delayed to prevent infection – what will
pregnancy, illegitimate child (watch closely) colonize the baby is the mother’s flora and not the
o Prevention of smoking, alcohol intake and exposure hospital’s flora
to teratogens o Prevents heat loss via convection
o Tetanus toxoid immunization for the mother most • Properly timed cord clamping and cutting between 1-3
specially when not giving birth in a health care minutes of life or until cord pulsations stop
facility. o Prevent anemia and intraventricular hemorrhage
o Maternal nutrition (to include folic acid specially in a premature infant
supplementation) • Non-separation of the newborn and mother for early
▪ Avoid neural tube defects breastfeeding (60-90 minutes)
• How long? Keep them together forever! The whole time
BREASTFEEDING the mother is in the delivery/operating room
• Nutritional, immunologic and intellectual benefits of
breastfeeding for the infant and mother (no artificial • TIME BOUND: SHOULD BE DONE IN SEQUENCE!
formula) – should be known by heart • Life saving because many of the deaths occur in the first
• Psychosocial advantages for both mother and infant hour of life.
• Potential decrease in risk for future chronic disease • Done only in well babies
(hypertension, obesity, type 2 diabetes, allergy) in the • Breastfeeding: Oxytocin and Prolactin
child • Duration of breastfeeding: 60-90 mins
• Health benefits for the mother
o Reduced post-partum bleeding due to oxytocin DIRECT ROOMING-IN
reflex that induces contraction leading to reduced • RA No. 7600 – the rooming in and breast feeding act of
bleeding post partum 1992
o Delayed return to fertility (exclusive breastfeeding • Adopts rooming in as a national policy to encourage,
for 6 months) – contraceptive effect protect and support the practice of breastfeeding
o Less risk for breast and ovarian malignancies • Mandates all hospitals and personnel to room-in all
o Promotes early return to pre-pregnancy weight normal newborns and carry out breastfeeding
• Economic and environment-friendly benefits of advocacy, initiation, and maintenance.
breastfeeding • Practice of placing the newborn in the same room as
o Safe, sterile, always available the mother right after delivery up to discharge to
• Cheap and comes in cute containers facilitate mother-infant bonding and to initiate
breastfeeding
NEWBORN CARE AND PROCEDURES • Normal spontaneous deliveries and c-section
• Essential Intrapartum And Newborn Care (EINC) o Latched on to the mother’s breast immediately
protocol after birth
• Time bound interventions which address the newborn’s • Should the mother choose not to room in or
primary needs breastfeed her newborn, a waiver form releasing the
o Thermal protection hospitals from all responsibilities should be
5M PEDIATRICS: Preventive Pediatrics 

o Maintenance of homeostatic metabolism documented and signed options for other methods of
o Protection from infection <>MA feeding shall be outline and appropriate support for her
• Involves all deliveries (NSVD or C-section) decision should be provided
• inform of repercussions and try your best to convince
FOUR (4) CORE ACTIONS *(visual image on page 5) the mother to breastfeed
• Immediate and thorough drying of the newborn (30-60 • Written waiver should be made by the patient herself in
st
seconds) – drying for the 1 minute of life her own words and with her signature
o Prevent loss of heat via evaporation
o Normal spontaneous deliveries
o Prevent hypothermia
▪ mother’s breast immediately afterbirth and
o Initiate first cry
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 roomed in within 30 mins o Organic acid disorders
o Caesarean section o Fatty acid oxidation disorders
▪ Roomed in and breastfed within 3-4 hours after o Disorders of amino acid metabolism
birth • Cost 1500 (available in our setting)

NEWBORN SCREENING NEWBORN HEARING SCREENING

• Republic act no 9288 – newborn screening act of 2004 • Republic act of 9709 – the universal newborn hearing
• An act of promulgating a comprehensive policy and a screening and intervention act of 2009
national system for ensuring newborn screening • Established for prevention and recognition of congenital
• To ensure that every baby born in the Philippines is hearing loss on newborns and infants
offered the opportunity to undergo newborn screening • All infants born in hospital in the Philippines must
• Secondary prevention – bec. condition is already present undergo hearing screen before discharge
• Performance of newborn screening • Infants not born in the hospital should undergo the test
o After 24 hours of life but not later than 3 days after within 3 months after birth
delivery of the newborn
o Newborn in the ICU must undergo newborn NEWBORN EYE SCREENING
screening by 7 days of age • Includes
o refusal: waiver should be secured and written on o Check for steady eyes (nystagmus)
the chart o White, lustrous conjunctiva
• Disorders tested heritable conditions o Clear cornea
o CH - Congenital hypothyroidism o Non-droopy eyelids
o CAH - Congenital adrenal hyperplasia o Pupillary reflex and red-orange reflex (ROR)
o GAL - Galactosemia • specially in premature newborns given oxygen therapy
o PKU - Phenylketonuria causing retinopathy of prematurity who may end up blind
o G6PD deficiency – Highest incidence among • Indications for referral to an ophthalmologist
Filipinos o Jiggly eyes, strabismus
o MSUD - Maple syrup urine disorder o Droopy eyelids, ptosis
o Non-reactive pupil
Disorder Screened Effect if not Effect if screened
screened and managed
o Red eye dry, frothy conjunctivae
CH Severe mental Normal o Opacities
retardation o Absent/ dull or asymmetric red orange reflex
CAH Death Alive and normal
GAL Death or Cataracts Alive and Normal Immunizations with Hepatitis B vaccine and BCG
PKU Severe Mental Normal - Done right after birth
Retardation
G6PD deficiency Severe Anemia, Normal ANTICIPATORY GUIDANCE (Prenatal period)
Kernicterus • Assessment of the child’s future exposure to or
MSUD Death Alive and normal prevention of neglect, maltreatment, and violence
- Results: 7-10 days of life or 10 to 14 days o Parents education
- (+) informed within 10-14 days o Profession
- (-) no news o Attitude regarding the pregnancy
- Official Results: After a month at the hospital where o Planned disciplinary method/ child rearing
woman gave birth approach
• Cost: 550 pesos o Financial security
• Heel prick on filter paper and sent to the national o Family support system
• Inquire about family history of genetic or chromosomal
5M PEDIATRICS: Preventive Pediatrics 

newborn centers for screening

• Once positive, do confirmatory tests in a continuity clinic abnormality and developmental disability
for newborns with metabolic disorders • Discuss about injury prevention and potential exposure
• If not screened, severe mental retardation for to environment toxicants such as lead
congenital hypothyroidism and other complications • Should be discussed even before child is born
• G6PD (most common): immediately inform parents about
the food that the infant should avoid. (early intervention) PREGNANT WOMEN PREVENTION
• Pregnant women must be informed about the
EXPANDED NEWBORN SCREENING deleterious effects of smoking, alcohol intake and
• Includes 22 more disorders (28 all in all) exposure to known teratogens (infections and drugs)
o Hemoglobinopathies during pregnancy
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• FDA: determines the potential to become teratogens o caretaker fatigue
Class X : avoid at all costs, inform mother to be careful when
taking in drugs or medications. • WHO child growth standards
o Used as reference standard for weight, height and
TETANUS TOXOID IMMUNIZATION head circumference
• Tetanus toxoid must be started or continued during o Interpretation of growth points are based on Z-
pregnancy scores (standard deviation scores) and not on
percentile scores
DIET o Body mass index (BMI) measurement standards
• Folic acid rich food to prevent neural tube defects enable early detection and prevention of
overweight and obesity problems
DISCHARGE OF HEALTHY TERM NEWBORN o Plot against growth charts that are color coded,
• Optimal time is decided by the physician caring for both beautiful
mother and child o Part of preventive aspect of every patient
• Obstetrician and Pediatrician should collaborate o Developmentalists spend hours with every patient
• For newborns discharged < 48 hours after delivery o Z score 0: normal
(more so if within 24 hours), a follow up must be made
within 48 hours of discharge then at about one month Notetakers:
• NSVD: within 48 hours
• C section: within 72 hours Gayle Francez Monique Tandoc
• More frequent visits required for sick neonates Lethmar Tolentino
(weekly/daily) Erika Monique Ang

INFANCY
• 2nd month of life up to 2 years old
• In order to ensure optimum health, monthly health
visits are recommended during the first year of life and
every other month during the second year
• History and thorough physical examination to assess
the following:
o Care and feeding of infant
o Developmental milestones (at par with age)
o Occurrence of symptoms during the interval
between visits
o Immunizations
o Anthropometric measurements

COMPLEMENTARY FEEDING
• Timely: introduced at 6 months of age
• Breast feeding until 2-3 years old (WHO)
• Adequate: provides sufficient energy, proteins and
micronutrients to sustain growth
• Safe: hygienically prepared and stored
• Properly fed: meal frequency and feeding methods
suitable for age (guide or self-feeding using clean hands,
spoon and fork, cups and bowls) use local fresh and
5M PEDIATRICS: Preventive Pediatrics 

natural foods
• Teach self feeding but know developmental milestone
suitable/appropriate for age

• Provide anticipatory guidance on injury prevention,

behavior and nutrition
• Assess relationship between infant and parents
o Be aware of risk factors for child abuse and neglect
such as prematurity, long hospital stay, presence of
disabilities, stresses in the family, etc.
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5M PEDIATRICS: Preventive Pediatrics 